Charleston Job Corps - Application for Employment

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, national origin, citizenship status, physical or mental disability, or past, present, or future service in the Uniformed Services of the U.S., or any other legally protected status. The use of this form does not mean there are positions open and does not obligate us in any way. This form uses 256-bit SSL encryption to protect your information during submission.

Name:
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First Name Last Name

Phone Number:
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-
Area Code Phone Number

E-mail Address:
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Address:
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Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Secondary Phone Contact

Can you produce documented proof of your eligibility for employment in the U.S.? (Driver's License, Social Security Card, INS Documents, etc.)

Have you ever been convicted of a violation of the law except a minor traffic violation?(A conviction will not necessarily disqualify you from employment)
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NO

Have you held a position of trust (handling money or confidential material)?
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NO

References

Please list two (2) references that are familiar with your work life.

Reference 1

Name:
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First Name Last Name

Phone Number
*

-
Area Code Phone Number

Years Known:
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Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Reference 2

Name:
*

First Name Last Name

Phone Number
*

-
Area Code Phone Number

Years Known:
*

Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Reference 3

Name:
*

First Name Last Name

Phone Number
*

-
Area Code Phone Number

Years Known:
*

Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Prior Work Record (Start with most recent/present employer and complete in full)

1. Name and Address of Most Recent Employer

Job Title/Duties

Supervisor Name and Phone Number

May we contact?

Yes No

Date Hired Date Left

Starting Rate Last Rate

2. Name and Address of Most Recent Employer

Job Title/Duties

Supervisor Name and Phone Number

May we contact?

Yes No

Date Hired Date Left

Starting Rate Last Rate

3. Name and Address of Most Recent Employer

Job Title/Duties

Supervisor Name and Phone Number

May we contact?

Yes No

Date Hired Date Left

Starting Rate Last Rate

Please provide any additional information such as special skills, training, experience, equipment operation, or other qualificationsyou feel will be helpful to us in considering your application

Upload Resume:

Upload Driver's License:

Upload Paycheck Stub:

Job Applicant’s Agreement and Certification

“I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the same right.”

“If I am offered employment, I agree to submit to a physical examination whenever requested, and I understand my becoming employed and/or my continued employment are subject to the results of any physical examination related to my job duties in accordance with company policies and procedures.”

“I understand that I will be required to take a drug test. I understand that I will be required to sign a drug free statement."

“I understand that if employed, policies, and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time.”

"I understand that this application will be kept on file for six months from the date completed, after which time I would have toreapply in accordance with established company procedures.”

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I agree

Background Check Information

Name
*

First Name Last Name

Maiden Name

Phone Number
*

-
Area Code Phone Number

Current Address
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Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Former Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Gender
*

Male Female

Date of Birth
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Month
-
Day Year

Place of Birth
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State of License
*

Name on License
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School Attended

School Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Degree

GED HS AS BS BA Masters PH.D

In connection with my application for employment (including contract for services or volunteers), I understand that investigative background inquiries are to be made on me, which may include criminal, civil litigation, motor vehicle, and other reports. These reports may include information as to my character, work habits, performance, education and experience along with reasons for termination of employment from previous employers. Further, I understand that you will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil and other experiences.

I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from any liability and responsibility for doing so. I hereby consent to obtaining the above information from any of their licensed agents. This authorization and consent shall be valid in original, fax or copy form. I further authorize ongoing procurement of the reports mentioned above at any time during my employment, (contract or volunteering).

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I agree

AGREEMENT, AUTHORIZATION, AND CONSENT FOR RELEASE OF BACKGROUND INFORMATION

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I understand that in conjunction with my application for employment, work to be performed under contract,promotion, volunteer position, reassignment, and/or retention ("Work") Horizons Youth Services will use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications. This agency will provide a written report of its findings to Horizons Youth Services.Horizons Youth Services uses Sterling Infosystems, Inc., a consumer-reporting agency, as an agent to perform its Employment related background investigations.Sterling Infosystems, Inc. will utilize various sources of information it deems appropriate including but not limited to: criminal conviction records, current and former employers, department of motor vehicle records,military records, credit reporting agencies, education records, professional and personal references and workers compensation records including any and all injuries in compliance with the Americans withDisabilities Act. I agree, authorize and consent to the release and disclosure of any and all information including but not limited to the above to Horizons Youth Services and Sterling Infosystems, Inc..I agree, authorize and consent to the procurement of a Consumer Report and/or an Investigative ConsumerReport and understand that it may contain information about my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This authorization in original or copy form shall be valid for my term of Work from the date indicated next to my signature. I understand and agree that where applied an electronic signature filed in electronic form shall have the same legal force and effect as my hand written signature. According to the Fair Credit Reporting Act, I will be notified by Horizons Youth Services if Work is denied because of information obtained from aConsumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to Horizons YouthServices. I further understand that I may request a copy of the report, and that when doing so, proper identification will be required and I should direct my request to: Sterling Infosystems, Inc., 5750 WestOaks Blvd, Ste 100, Rocklin, CA 95765 Phone #: 800.943.2589, option 1, Website:www.sterlinginfosystems.com. I understand that residents of all states will automatically receive a copy of the report if an adverse action is taken regarding the employment application, or upon request as outlined herein.

Voluntary Identification Form

As a government contractor, Horizons Youth Services complies with various laws and regulations that require us to file annual statistical reports on applicants for employment. In addition, we wish to comply with the various laws and regulations which protect handicapped, disabled veterans and veterans who served on active duty during the Vietnam era for more than 180 days. Submitting this information is voluntary and has no bearing on the hiring/employment process. This supplement will be maintained separately from your application and personnel file.

Name

First Name Last Name

Date

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Month
-
Day Year

Position for which you are applying

Horizons Youth Services is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:• A “disabled veteran” is one of the following:• A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or• a person who was discharged or released from active duty because of a service-connected disability.• A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.• An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.• An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), tollfree, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM NOT A PROTECTED VETERAN

As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.

I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

Disabled Veteran Recently Separated Veteran Active Wartime or Campaign Badge Veteran Armed Forces Service Medal Veteran I am a protected veteran, but I choose not to self-identify the classifications to which I belong I am NOT a protected veteran

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

APPLICANTS IDENTIFYING THEIR SEX AND RACE

Gender Classification

Female Male

EEO Classification

Hispanic or Latino White (not Hispanic or Latino) Black or African American (not Hispanic or Latino) Asian (not Hispanic or Latino) American Indian or Alaskan Native (not Hispanic or Latino)

Referral Source

Advertisement Agency Employee Job Fair Job Posting School

Voluntary Self–Identification of Disability Form

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.[i] To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

[i] Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Please check one of the boxes

YES, I HAVE A DISABILITY (or previously had a disability) NO, I DON’T HAVE A DISABILITY I DON’T WISH TO ANSWER

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

[1] Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.